From the Guidelines
In cardiogenic shock, norepinephrine is the recommended first-line vasopressor, followed by consideration of other agents as needed, with the goal of optimizing blood pressure and organ perfusion while minimizing risks. The use of vasopressors in cardiogenic shock is guided by the principle of supporting blood pressure and organ perfusion while addressing the underlying cause of shock 1.
Key Considerations
- Norepinephrine is preferred for its balanced alpha-adrenergic vasoconstriction and modest beta-adrenergic effects, which support cardiac function with less risk of tachycardia and arrhythmias compared to other options 1.
- Vasopressin may be considered as a second agent, especially in patients who become catecholamine-resistant, due to its non-adrenergic mechanism of action 1.
- Epinephrine and dobutamine may be used for additional inotropic support but carry higher risks of tachyarrhythmias and increased myocardial oxygen demand 1.
- Dopamine is generally avoided due to its higher association with arrhythmias and mortality 1.
Recent Guidelines
The most recent guideline from 2022 emphasizes the importance of a multidisciplinary team approach in managing cardiogenic shock and considers temporary mechanical circulatory support for patients not responding to initial measures 1.
Clinical Approach
The clinical approach should prioritize the use of norepinephrine as the first-line vasopressor, with careful consideration of the addition of other agents based on patient response and clinical context. It's crucial to monitor patients closely and adjust therapy as needed to optimize outcomes in cardiogenic shock 1.
From the FDA Drug Label
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action Vasopressin causes vasoconstriction by binding to V1 receptors on vascular smooth muscle coupled to the Gq/11-phospholipase C-phosphatidyl-inositol-triphosphate pathway, resulting in the release of intracellular calcium.
- 2 Pharmacodynamics At therapeutic doses exogenous vasopressin elicits a vasoconstrictive effect in most vascular beds including the splanchnic, renal and cutaneous circulation.
In patients with vasodilatory shock vasopressin in therapeutic doses increases systemic vascular resistance and mean arterial blood pressure and reduces the dose requirements for norepinephrine.
The best vasopressors to use in cardiogenic shock are not directly stated in the provided drug label. However, based on the information provided, vasopressin can be used to increase systemic vascular resistance and mean arterial blood pressure in patients with vasodilatory shock, and it reduces the dose requirements for norepinephrine.
- The order of use is not specified in the label.
- Norepinephrine is mentioned as a drug that can be used in conjunction with vasopressin, but the label does not provide information on the order of use or the best vasopressors for cardiogenic shock specifically 2.
From the Research
Vasopressor Use in Cardiogenic Shock
- The use of vasopressors in cardiogenic shock is limited by their side-effects and the lack of solid evidence regarding their effectiveness in improving outcomes 3, 4, 5.
- Norepinephrine is recommended as the first-line vasopressor agent due to its minimal adverse effects and association with the best outcome in network meta-analyses 3, 6, 5.
Order of Vasopressor Use
- Norepinephrine is the first-line agent when blood pressure needs to be restored 3, 4, 6, 5.
- Vasopressin may be an excellent alternative in tachycardiac patients or in the presence of pulmonary hypertension 3, 6.
- Epinephrine may be used as an alternative, but it is associated with an increased incidence of refractory shock and observational studies suggest an increased risk of death 6, 7.
- Angiotensin II and dopamine have limited indications and may be used in specific situations 5.
Inotrope Use in Cardiogenic Shock
- Dobutamine is the first-line inotrope agent, while levosimendan can be used as a second-line agent or preferentially in patients previously treated with beta-blockers 4, 6.
- The impact on outcome of inotropic agents remains controversial, and their use should be limited to a temporary measure as a bridge to recovery, mechanical circulatory support, or heart transplantation 3, 4, 6.